This document discusses heart failure with preserved ejection fraction (HFpEF). It makes several key points:
1. HFpEF represents 50% of heart failure cases and its prevalence is increasing annually. It causes similar functional decline and hospital readmissions as heart failure with reduced ejection fraction (HFrEF) but is not "benign" as previously thought.
2. Diagnosing HFpEF requires diligence as symptoms are nonspecific and biomarkers like BNP can be normal. Echocardiography should show evidence of diastolic dysfunction and elevated pulmonary artery pressures help identify HFpEF.
3. Dynamic testing with exercise echocardiography or cardiac catheterization may be needed to confirm the
Heart Failure with Preserved Ejection Fraction(HFpEF).ptxSarfraz Saleemi
Heart failure with preserved ejection fraction (HFpEF) is not one disease but a clinical syndrome presenting with symptoms of Heart Failure with a left ventricular ejection fraction (LVEF) ≥50 percent and evidence of cardiac diastolic dysfunction. (abnormal LV filling pattern and elevated filling pressures)
It is more common among older patients and women, and results from abnormalities of active ventricular relaxation and passive ventricular compliance. HFpEF should be part of differential diagnosis in patients with typical symptoms such as fatigue, weakness, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, edema and clinical signs of chronic heart failure. Echocardiography features of normal ejection fraction with impaired diastolic function confirm the diagnosis.
Heart Failure with Preserved Ejection Fraction(HFpEF).ptxSarfraz Saleemi
Heart failure with preserved ejection fraction (HFpEF) is not one disease but a clinical syndrome presenting with symptoms of Heart Failure with a left ventricular ejection fraction (LVEF) ≥50 percent and evidence of cardiac diastolic dysfunction. (abnormal LV filling pattern and elevated filling pressures)
It is more common among older patients and women, and results from abnormalities of active ventricular relaxation and passive ventricular compliance. HFpEF should be part of differential diagnosis in patients with typical symptoms such as fatigue, weakness, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, edema and clinical signs of chronic heart failure. Echocardiography features of normal ejection fraction with impaired diastolic function confirm the diagnosis.
1. A Case report of Heart Failure
2. Discussion on Heart Failure
3. Role of Peptides in Heart Failure
4. Importance of 30 days in heart failure
5. Role of ENTRESTO in Stable Heart Failure patient (PARADIGM-HF study)(HFrEF)
6. Biomarkers in Heart Failure
7. Role of ARNI in Hospitalized Heart Failure patient (PIONEER-HF study)
8. Role of ARNI in HFpEF (PARAMOUNT Trial)
9. Safety and usefulness of ACEI/ARB/ARNI
10. Role of SGPL2 inhibitors in HF with/without DM
Javed Butler, MD, MPH, MBA, discusses heart failure in this CME activity titled, "New Frontiers in Managing Heart Failure: Are SGLT2 Inhibitors the Next Leap Forward in Optimizing Patient Care?" For the full presentation, downloadable infographics, monograph, complete CME information, and to apply for credit, please visit us at http://bit.ly/2JG2v9l. CME credit will be available until May 29, 2020.
#flozins
🫀DAPA 🆚placebo in HFpEF
Now we have a positive trial!
⬇️18% in CV☠️ death or
worsening HF among LVEF>40%
⬇️ 21%heart failure
💥Results same for LVEF> 60% 🆚LVEF<60%
http://www.theheart.org/web_slides/1416535.do
A trial to compare Fractional Flow Reserve versus Angiography for Guiding PCI in Patients with Multivessel Coronary Artery Disease II
1. A Case report of Heart Failure
2. Discussion on Heart Failure
3. Role of Peptides in Heart Failure
4. Importance of 30 days in heart failure
5. Role of ENTRESTO in Stable Heart Failure patient (PARADIGM-HF study)(HFrEF)
6. Biomarkers in Heart Failure
7. Role of ARNI in Hospitalized Heart Failure patient (PIONEER-HF study)
8. Role of ARNI in HFpEF (PARAMOUNT Trial)
9. Safety and usefulness of ACEI/ARB/ARNI
10. Role of SGPL2 inhibitors in HF with/without DM
Javed Butler, MD, MPH, MBA, discusses heart failure in this CME activity titled, "New Frontiers in Managing Heart Failure: Are SGLT2 Inhibitors the Next Leap Forward in Optimizing Patient Care?" For the full presentation, downloadable infographics, monograph, complete CME information, and to apply for credit, please visit us at http://bit.ly/2JG2v9l. CME credit will be available until May 29, 2020.
#flozins
🫀DAPA 🆚placebo in HFpEF
Now we have a positive trial!
⬇️18% in CV☠️ death or
worsening HF among LVEF>40%
⬇️ 21%heart failure
💥Results same for LVEF> 60% 🆚LVEF<60%
http://www.theheart.org/web_slides/1416535.do
A trial to compare Fractional Flow Reserve versus Angiography for Guiding PCI in Patients with Multivessel Coronary Artery Disease II
The two major causes of acute right ventricular (RV) failure in ICU patients are acute cor pulmonale (ACP) during acute respiratory distress syndrome (ARDS) and ACP during acute massive pulmonary embolism (PE).
The increase in pulmonary vascular resistance (PVR) in ARDS can be secondary either to « structural » mechanisms related to lung injury per se and to « functional » mechanisms related to the effects of mechanical ventilation with positive end expiratory pressure (PEEP). The latter mechanism is enhanced when PEEP overdistends more than it recruits lung volume and when tidal volume (VT) is high. The recommended protective ventilation with low VT and PEEP adjusted to driving pressure can also reduce the RV afterload. A reduced central blood volume can also play a role in the increase in PVR (extension of the West’s zone 2). In this case, volume administration can reduce the PVR and improve the RV function. Finally, prone positioning also exerts a beneficial effect on RV afterload through a decrease in PVR (lung recruitment, decrease in hypoxic vasoconstriction, increase in central blood volume with decrease in the extent of zone 2).
In acute PE, RV dysfunction is associated with poor outcome. Thrombolytic treatment, which is indicated in cases of severe PE with shock, prevents hemodynamic decompensation in patients with intermediate risk PE, but also results in increased risk of severe hemorrhage and stroke. In the case of PE with low cardiac output and no RV dilatation, fluid administration can be indicated to improve cardiac output. In cases of systemic arterial hypotension, vasopressors such as norepinephrine can be indicated to restore adequate RV perfusion pressure. Indication of inotropic agents such as dobutamine, which improves the RV-pressure artery coupling should be evaluated individually. Surgical pulmonary embolectomy can be indicated when the thrombolytic therapy is contra-indicated in acute PE with shock.
Cardiogenicshock by Dr.Afroza Prioty -140123092109-phpapp02Afroza Prioty
A small overview on cardiogenic shock which sometimes becomes a burning issue for the medical personnels and to combat the situation, the measures should be taken immediately and urgently.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
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The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
1. Heart FailureHeart Failure
withwith
Preserved Ejection Fraction (HFpEF):Preserved Ejection Fraction (HFpEF):
How to diagnose, What to do about it?How to diagnose, What to do about it?
Dr.Vinod SharmaDr.Vinod Sharma
11
National Heart InstituteNational Heart Institute
2. Heart Failure with PreservedHeart Failure with Preserved
Ejection Fraction (HFpEF)Ejection Fraction (HFpEF)
A leading cause of morbidity & mortality.A leading cause of morbidity & mortality.
Represents 50% of HF cases.Represents 50% of HF cases.
Prevalence of HFpEF relative to HFrEF isPrevalence of HFpEF relative to HFrEF is
increasing at rate of 1% per year.increasing at rate of 1% per year.
22
3. Heart Failure with PreservedHeart Failure with Preserved
Ejection Fraction (HFpEF)Ejection Fraction (HFpEF)
4. Similar functional decline, hospitalSimilar functional decline, hospital
readmission rates, economic costs asreadmission rates, economic costs as
HFrEFHFrEF
Key Lesson # 1Key Lesson # 1
HFpEF is not “benign”HFpEF is not “benign”
5. HFpEF, are as functionally limited as their counterpart with
HFrEF
Survival is poor & similar to HFrEFSurvival is poor & similar to HFrEF
55
Heart Failure with Preserved EjectionHeart Failure with Preserved Ejection
Fraction (HFpEF) -Fraction (HFpEF) - PrognosisPrognosis
Observational study – dismal 5 year survival of only 35 – 40%Observational study – dismal 5 year survival of only 35 – 40%
post hospitalization for HFpost hospitalization for HF
EJM 2006: 355: 251-9EJM 2006: 355: 251-9
““a survival rate similar to advanced, stage 3B, non small cella survival rate similar to advanced, stage 3B, non small cell
lung cancer”lung cancer”
Key reason of high morbidity & mortality of HFpEF is lack ofKey reason of high morbidity & mortality of HFpEF is lack of
evidence based treatment.evidence based treatment.
9. Key Lesson # 3Key Lesson # 3
99
Know the difference between Diastolic
dysfunction, Diastolic Heart Failure &
HFpEF
10. Heart Failure with PreservedHeart Failure with Preserved
Ejection Fraction (HFpEF)Ejection Fraction (HFpEF)
Diastolic dysfunction is not unique to DHF.Diastolic dysfunction is not unique to DHF.
Echo evidence of DD is nearly universal inEcho evidence of DD is nearly universal in
HFrEF (systolic HF).HFrEF (systolic HF).
Isolated or pure DHF is rare.Isolated or pure DHF is rare.
Only 2% of patient met criteria for DHFOnly 2% of patient met criteria for DHF
Prasad et al: Circ Heart Fail 2010Prasad et al: Circ Heart Fail 2010
1010
14. Symptoms are nonspecific and can be explained bySymptoms are nonspecific and can be explained by
several alternative non-cardiac conditions viz COPD,several alternative non-cardiac conditions viz COPD,
CKD, anemiaCKD, anemia
Many patients are morbid obese:Many patients are morbid obese:
-- Difficulty estimating JVPDifficulty estimating JVP
-- Estimation of RA pressure by assessment of sizeEstimation of RA pressure by assessment of size
and collapsibility of IVC challengingand collapsibility of IVC challenging
No simple Index (viz. Low EF) to rule in the diagnosisNo simple Index (viz. Low EF) to rule in the diagnosis
of HFpEFof HFpEF
1414
HFpEF : Diagnosis & ManagementHFpEF : Diagnosis & Management
15. Simultaneous & obligatory presence of:Simultaneous & obligatory presence of:
-- Signs and / or symptoms of HFSigns and / or symptoms of HF
-- Evidence of normal EF (EFEvidence of normal EF (EF >> 50%) & LV end diasotlic volume50%) & LV end diasotlic volume
Index < 97 ml / mIndex < 97 ml / m22
-- Evidence of diastolic dysfunctionEvidence of diastolic dysfunction
Emphasis on DD in these guidelines not necessarily implies thatEmphasis on DD in these guidelines not necessarily implies that
DD is the only underlying mechanism of HFpEFDD is the only underlying mechanism of HFpEF
1515
Diagnosis of HFpEFDiagnosis of HFpEF
Presence of DD (grade 2+), along with LA enlargement, anPresence of DD (grade 2+), along with LA enlargement, an
objective way of assessing presence of increased LV fillingobjective way of assessing presence of increased LV filling
pressurepressure Eur Heart J 2012: 33: 1750-7Eur Heart J 2012: 33: 1750-7
Eur Heart J 2007: 28: 2539-50Eur Heart J 2007: 28: 2539-50
Circulation 200: 101: 2118-21Circulation 200: 101: 2118-21
16. A Normal B-Type Natriuretic
Peptide Does not Exclude the
diagnosis of HFpEF
1616
HFpEF : Diagnosis & ManagementHFpEF : Diagnosis & Management
Key Lesson # 5
17. Elevated levels of BNP & NT-Pro BNP are potentElevated levels of BNP & NT-Pro BNP are potent
predictors of adverse outcome in HF regardless ofpredictors of adverse outcome in HF regardless of
underlying EF.underlying EF.
BNP is less sensitive for diagnosis of HFpEFBNP is less sensitive for diagnosis of HFpEF
compared to HFrEFcompared to HFrEF
Maisel A et al: JACC: 2003: 41:2010-17Maisel A et al: JACC: 2003: 41:2010-17
BNP levels more accuratelyBNP levels more accurately reflects wall stressreflects wall stress
compared to LV filling pressure. LV wall stress iscompared to LV filling pressure. LV wall stress is
known to be lower in HFpEF than HFrEFknown to be lower in HFpEF than HFrEF..
Iwanaga Y JACC: 2006: 47: 742-8Iwanaga Y JACC: 2006: 47: 742-8
1717
HFpEF : Diagnosis & ManagementHFpEF : Diagnosis & Management
18. Up to 30% of patients with HFpEF have BNP levels <Up to 30% of patients with HFpEF have BNP levels <
100 pg/ml despite HF signs & symptoms and invasive100 pg/ml despite HF signs & symptoms and invasive
hemodynamic evidence of elevated LV filling pressurehemodynamic evidence of elevated LV filling pressure
Obesity, very common with HFpEF, associated withObesity, very common with HFpEF, associated with
low BNP levels.low BNP levels.
While BNP levels are powerful & independentWhile BNP levels are powerful & independent
predictors of future events in patients with HFpEFpredictors of future events in patients with HFpEF,, aa
normal BNP level cannot exclude the diagnosis ofnormal BNP level cannot exclude the diagnosis of
HFpEF in patients, who have sign & symptoms of HFHFpEF in patients, who have sign & symptoms of HF..
1818
HFpEF :HFpEF : Diagnosis & ManagementDiagnosis & Management
(contd…)(contd…)
19. Elevated Pulmonary Artery Systolic
Pressure on Echocardiography with a
normal LVEF?
Consider HFpEF
1919
HFpEF : Diagnosis & ManagementHFpEF : Diagnosis & Management
Key Lesson # 6
20. ““Frequency of elevated Pulmonary arteryFrequency of elevated Pulmonary artery
systolic pressure (PASP) among patients withsystolic pressure (PASP) among patients with
HFpEF is 83%”HFpEF is 83%”
LAM et al: JACC: 2009: 53: 1119-26LAM et al: JACC: 2009: 53: 1119-26
PASP by Doppler Echocardiography a betterPASP by Doppler Echocardiography a better
predictor of HFpEF compared to other echopredictor of HFpEF compared to other echo
parameters associated with DDparameters associated with DD
-- E/e’ ratioE/e’ ratio
-- LA VolumeLA Volume
-- LV wall thicknessLV wall thickness
If patients with normal EF,If patients with normal EF, elevated PASP iselevated PASP is
suggestive of HFpEF until proved otherwisesuggestive of HFpEF until proved otherwise.. 2020
HFpEF : Diagnosis & ManagementHFpEF : Diagnosis & Management
21. Use Dynamic Testing to EvaluateUse Dynamic Testing to Evaluate
unexplained Dyspnea or Exerciseunexplained Dyspnea or Exercise
Intolerance when consideringIntolerance when considering
Diagnosis of HFpEFDiagnosis of HFpEF
2121
HFpEF : Diagnosis & ManagementHFpEF : Diagnosis & Management
Key Lesson # 7
26. Diagnosing HFpEF is ChallengingDiagnosing HFpEF is Challenging
so be thorough and considerso be thorough and consider
invasive hemodynamic testing toinvasive hemodynamic testing to
Confirm the DiagnosisConfirm the Diagnosis
2626
HFpEF : Diagnosis & ManagementHFpEF : Diagnosis & Management
Key Lesson # 8
27. How to diagnose HFpEF. We propose ‘elevatedHow to diagnose HFpEF. We propose ‘elevated
PCWP during exercise’ as a new criterion forPCWP during exercise’ as a new criterion for
(early) HFpEF(early) HFpEF
2727
28. Look for CAD in All PatientsLook for CAD in All Patients
with HFpEFwith HFpEF
2828
HFpEF : Diagnosis & ManagementHFpEF : Diagnosis & Management
Key Lesson # 9
29. CAD is less prevalent in HFpEF compared to thoseCAD is less prevalent in HFpEF compared to those
with HFrEFwith HFrEF
Yancy CW: JACC: 2006: 47:76-84Yancy CW: JACC: 2006: 47:76-84
Prevalence of CAD in HFpEF approx 56%Prevalence of CAD in HFpEF approx 56%
Steinberg et al: Circulation 2012:126:65-75Steinberg et al: Circulation 2012:126:65-75
Presence of CAD is associated with increased risk ofPresence of CAD is associated with increased risk of
developing HFpEF and increased mortality in patientsdeveloping HFpEF and increased mortality in patients
with HFpEFwith HFpEF
Judge K W et al: JACC: 1991: 10: 377-82Judge K W et al: JACC: 1991: 10: 377-82
2929
HFpEF : Diagnosis & ManagementHFpEF : Diagnosis & Management
30. Conceptual model of pathophysiology linking coronary microvascularConceptual model of pathophysiology linking coronary microvascular
ischemia, low-level cardiomyocyte injury and myocardial stiffness toischemia, low-level cardiomyocyte injury and myocardial stiffness to
major adverse cardiovascular outcomes (MACE), especially heart failuremajor adverse cardiovascular outcomes (MACE), especially heart failure
with preserved ejection fraction. This process may occur even in thewith preserved ejection fraction. This process may occur even in the
absence of obstructive coronary artery or overt structural heart disease.absence of obstructive coronary artery or overt structural heart disease.
31. CAD, a treatable condition, symptoms can mimic HF.CAD, a treatable condition, symptoms can mimic HF.
Systemic evaluation is importantSystemic evaluation is important
High pretest probability of CAD in HFpEF, negativeHigh pretest probability of CAD in HFpEF, negative
stress test for CAD may not reliably exclude CADstress test for CAD may not reliably exclude CAD
-- Proceed with CAG in all patients with HFpEFProceed with CAG in all patients with HFpEF
unless contraindicatedunless contraindicated
Shah S J et al: Curr Treat options Cardiovasc Med 2010: 12: 58 - 75Shah S J et al: Curr Treat options Cardiovasc Med 2010: 12: 58 - 75
3131
HFpEF : Diagnosis & ManagementHFpEF : Diagnosis & Management
(contd….)(contd….)
32. Understand the importanceUnderstand the importance
of Heart Rate in HFpEFof Heart Rate in HFpEF
3232
HFpEF : Diagnosis & ManagementHFpEF : Diagnosis & Management
Key Lesson # 10
33. HR and pathophysiology of HFpEF, a complexHR and pathophysiology of HFpEF, a complex
relationship:-relationship:-
-- Elevated HR is known to be associatedElevated HR is known to be associated
withwith increased mortality andincreased mortality and
hospitalization in HFpEF.hospitalization in HFpEF.
-- Chronotropic incompetence is prevalent inChronotropic incompetence is prevalent in
heart failure & plays important role inheart failure & plays important role in
pathogenesis of HFpEFpathogenesis of HFpEF
3333
HFpEF : Diagnosis & ManagementHFpEF : Diagnosis & Management
34. -- HR lowering agents suggested to beHR lowering agents suggested to be
beneficial for LV filling bybeneficial for LV filling by increasingincreasing
diastolic filling period. However,diastolic filling period. However,
-- HR response to exercise should beHR response to exercise should be
determined with exercisedetermined with exercise testing intesting in
HFpEFHFpEF
-- If chronotropic incompetenceIf chronotropic incompetence present ratepresent rate
– adaptive pacemaker implantation– adaptive pacemaker implantation should beshould be
considered to improve exerciseconsidered to improve exercise tolerancetolerance
3434
HFpEF : Diagnosis & ManagementHFpEF : Diagnosis & Management
(contd….)(contd….)
35. Remember the “ZEBRAS”Remember the “ZEBRAS”
when evaluating patients withwhen evaluating patients with
HFpEFHFpEF
3535
HFpEF : Diagnosis & ManagementHFpEF : Diagnosis & Management
Key Lesson # 11
39. Categorize HFpEF patients into clinicalCategorize HFpEF patients into clinical
phenotypes to help determine the bestphenotypes to help determine the best
management strategy in individualmanagement strategy in individual
patientpatient
3939
HFpEF : Diagnosis & ManagementHFpEF : Diagnosis & Management
Key Lesson # 12
40. 4040
Management of HFpEF by PhenotypeManagement of HFpEF by Phenotype
classificationclassification
41. It is possible to treat HFpEF –It is possible to treat HFpEF –
Treat by treating underlying co-Treat by treating underlying co-
morbiditiesmorbidities
4141
HFpEF : Diagnosis & ManagementHFpEF : Diagnosis & Management
Key Lesson # 13
42. Selected Recent or Pending HFpEFSelected Recent or Pending HFpEF
Randomized Controlled TrialsRandomized Controlled Trials
4242
43. Over the decades the prognosis of HFrEF hasOver the decades the prognosis of HFrEF has
improved significantly but despite the use ofimproved significantly but despite the use of
similar pharmacological agents, prognosis ofsimilar pharmacological agents, prognosis of
HFpEF remains unchanged.HFpEF remains unchanged.
All class of drugs (ACEI, ARB’s, BB, DIG) haveAll class of drugs (ACEI, ARB’s, BB, DIG) have
failed to show significant benefit in Rx offailed to show significant benefit in Rx of
HFpEFHFpEF
4343
HFpEF : Diagnosis & ManagementHFpEF : Diagnosis & Management
44. ““Drug treatment effects onDrug treatment effects on
outcomes in heart failure withoutcomes in heart failure with
preserved ejection fraction: apreserved ejection fraction: a
systematic review and meta-systematic review and meta-
analysis”.analysis”.
Sean Lee Zheng, Fiona T Chan, Adam A Nabeebaccus Ajay MSean Lee Zheng, Fiona T Chan, Adam A Nabeebaccus Ajay M
Shah, Theresa McDonagh, Darlington O Okonko, Salma AyisShah, Theresa McDonagh, Darlington O Okonko, Salma Ayis
Heart 2017; 0; 1-9 doi: 10.1136/heartjnlHeart 2017; 0; 1-9 doi: 10.1136/heartjnl
4444
HFpEF : Diagnosis & ManagementHFpEF : Diagnosis & Management
45. 4545
HFpEF : Diagnosis & ManagementHFpEF : Diagnosis & Management
RCT of pharmacotherapy in HFpEF ofRCT of pharmacotherapy in HFpEF of >> 40% have40% have
been disappointing with no convincingbeen disappointing with no convincing
demonstration of mortality or morbidity reduction.demonstration of mortality or morbidity reduction.
Result of meta-analysis shows significant reductionResult of meta-analysis shows significant reduction
in all cause and CV mortality in RCT usingin all cause and CV mortality in RCT using
betablockers, while RAAS blockade (ACEI, ARB, &betablockers, while RAAS blockade (ACEI, ARB, &
MRA individually) demonstrated no effect onMRA individually) demonstrated no effect on
mortality.mortality.
Improvement in functional outcomes & quality of lifeImprovement in functional outcomes & quality of life
were not significant and consistently demonstrated.were not significant and consistently demonstrated.
46. HFpEF is a syndrome and not a specific diseaseHFpEF is a syndrome and not a specific disease
process.process.
Overwhelming majority of patients with HFpEF haveOverwhelming majority of patients with HFpEF have
elevated LV filling pressure at rest & / or withelevated LV filling pressure at rest & / or with
exertion.exertion.
Severity of left atrial pressure elevation, volumeSeverity of left atrial pressure elevation, volume
retention and consequent pulmonary hypertensionretention and consequent pulmonary hypertension
with RV dysfunction is variable, as are the aetiologicwith RV dysfunction is variable, as are the aetiologic
& pathophysiologic path by which invididual develop& pathophysiologic path by which invididual develop
HFpEFHFpEF
4646
HFpEF : Diagnosis & ManagementHFpEF : Diagnosis & Management
Key Lesson # 13
“One Size fits all” treatment strategy
is unlikely to work for HFpEF
47. Theoretical Schema of Heart Failure with PreservedTheoretical Schema of Heart Failure with Preserved
Ejection Fraction patient types, Risk Profiles, and MatchedEjection Fraction patient types, Risk Profiles, and Matched
TherapiesTherapies
4747
49. Sensors, Scissors, Grasper,Sensors, Scissors, Grasper,
Slitter, Cutter & Driller areSlitter, Cutter & Driller are
entering into the managemententering into the management
of HFpEF.of HFpEF.
4949
HFpEF : Diagnosis & ManagementHFpEF : Diagnosis & Management
Key Lesson # 14
50. CardioMEMS HF System for Pulmonary PressureCardioMEMS HF System for Pulmonary Pressure
Monitoring in Heart Failure Patients Approved by FDAMonitoring in Heart Failure Patients Approved by FDA
5050
51. LA Strain When EjectionLA Strain When Ejection
Fraction is PreservedFraction is Preserved
5151
54. Reduce LAP – HF TrialReduce LAP – HF Trial
To evaluate the safety & performance ofTo evaluate the safety & performance of
the Interatrial septal defect system in thethe Interatrial septal defect system in the
treatment of HF patients with elevated LAtreatment of HF patients with elevated LA
pressure despite appropriate medicalpressure despite appropriate medical
treatment.treatment.
Feldman et al; Circulation AHAFeldman et al; Circulation AHA
Nov 2017Nov 2017
5454
59. ““Huffing & Puffing” (dyspnoea & exercise intolerance)Huffing & Puffing” (dyspnoea & exercise intolerance)
are most common symptom.are most common symptom.
““Huff – Puff”Huff – Puff”
““To complain noisily about something but not be ableTo complain noisily about something but not be able
to do anything about it”.to do anything about it”.
Clinician may approach HFpEF with diagnostic &Clinician may approach HFpEF with diagnostic &
therapeutic nihilism & consider there patient astherapeutic nihilism & consider there patient as
untreatable and difficult to manage because of lack ofuntreatable and difficult to manage because of lack of
guidelines & treatment options.guidelines & treatment options.
Diagnosis & treatment of HFpEF requires diligence &Diagnosis & treatment of HFpEF requires diligence &
hypervigilance.hypervigilance. 5959
HFpEF: “Huff Puff”HFpEF: “Huff Puff”